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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 05/16/2022
Date Signed: 05/16/2022 12:49:00 PM


Document Has Been Signed on 05/16/2022 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:JBM RESIDENCE HOME, INC.FACILITY NUMBER:
197607012
ADMINISTRATOR:JOSEPHINE B. MIRANDAFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 6DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Josephine B. Miranda TIME COMPLETED:
01:10 PM
NARRATIVE
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At 12:00 p.m., Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an infection control annual inspection. LPA was greeted by Administrator Josephine Miranda and LPAs temperature was taken; LPA was asked to sign the visitor’s log. LPA l Administrator. The purpose of the visit was explained, and an entrance interview was conducted.

Physical plant: At 12:10 p.m., LPA toured the facility. LPA observed table and chairs to be in adequate repair. LPA observed there to be no obstructions of passageways. Wall and floors were adequate, clean, and in good repair. Trash cans were observed to have lids.

The kitchen area: LPA observed the kitchen area to be adequately clean. Sharps are kept locked and inaccessible to clients. LPA observed the fire extinguisher's last date of purchase to be 2/24/2020.

Common rooms: There is a designated laundry area where cleaning supplies are stored. This room leads to an attached garage. The cleaning supplies are kept locked and inaccessible to clients. PPE supplies were readily available for clients and staff.

Deficiencies were issued per CA Code of Regulations Title 22. An exit interview was conducted. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/16/2022 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: JBM RESIDENCE HOME, INC.
FACILITY NUMBER: 197607012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited as the fire extinguisher was purchased on 2/24/2020 and has not been serviced since which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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The licensee will have the fire extinguisher serviced or purchase a new one by the POC due date. Proof of service or new purchase of fire extinguisher date to be sent to LPA by e-mail.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2